FON Care Center Application (2024)

FON Care Center Application

(2024)

Organization Name*

Mailing Address

City

State

Zip

PI Name*

First and Last Name

Point of Contact Name

Please describe your current system of Fontan Care

1. Considering the past 5 years, on average, how many individuals have had Fontan surgery performed at your center annually?*

Approximately how many individuals with Fontan circulation receive “regular care” at your institution for planned outpatient cardiology care - whether as part of a dedicated Fontan clinic or not?*

Do you see any obstacles to enrolling patients across the lifespan?*

Select or enter value

Please describe how the transition from pediatric to adult care works at your center. For example, is there an age cut-off or are most adults seen at another institution?*

Do you currently have or plan to put in place a partnership with an adult cardiac care center?*

Describe your organization

What does your organization hope to accomplish as a participant in FON?*

Please add any additional information about your organization that may be relevant to your participation in FON

Complete the Senior Leader/Administrator Agreement

Please complete this brief Senior Leader/Administrator Agreement. * The Senior leader should be someone outside of the primary FON team that has administrative responsibilities/ oversight for the cardiology clinic.

Name*

Individual with SVCHD

Name

First and Last

Credentials

Title

Phone

Parent of a Child with SVCHD

Name

First and Last

Credentials

Title

Phone

Other Team Members

Name

First and Last

Role on Team

Credentials

Title

Phone

Name

First and Last

Role on Team

Credentials

Title

Phone

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